Routine Immunization

Dr SD Khaparde
Deputy Commissioner (I.D &Imm)
Ministry of Health & Family Welfare
Government of India
 India: Profile
• Province/states: 35
• Districts:
Di t i t 610
• Blocks: 5564

• Projected Infants (2007): ~ 27 million

 Child Health Programmes
g
1978- Expanded
p Programme
g of immunization (EPI)
( )

1984- Universal Immunization Programme (UIP) For

prevention of deaths due to 6 VPDs

1985- Oral Rehydration Therapy Programme for prevention of

deaths due to diarrhoea

1990- UIP and ORT universalized in all districts

1990- ARI Programme taken up as a pilot in 26 districts

1992- CSSM

1997- RCH-1
•The focus is a District
•District Action planning
2005-
2005 NRHM and RCH II
•Effectiveness
Eff ti off policy
li &
coordination at District
 NATIONAL GOALS & MDG
X FY Plan NPP MDG
Current
2007 2010 2015

Infant MR 45 <30 27 55
(SRS 2008)

Maternal MR 200 <100 100 301

(SRS 01-03)

Total fertility R 2.1 2.1 2.9

Institutional 40 7
40.7
80% 80%
deliveries (NFHS III)
4
 SITUATIONAL ANALYSIS

Evaluated coverage of 43.5%

43 5% by NFHS 3 and 62
62.4%
4% by UNICEF CES 2006 fully
immunized children

8% 62 4
62.4

54.5

1.5%
5%
42 43.5

20 lac more
children
fully
immunized
in one year
y

NFHS 2 NFHS 3 CES 2005 CES 2006

5
 Immunization coverages increased in traditionally low performing states
(NFHS 2-3)
NFHS 2 FI data 26.9
25.7
0-9%
10-19% 21.2 22.2
20.5
20-29% 18.5 19.1
17.7
30-39% 14.6
40 49%
40-49%
50-59% 9.2 10
8.1 9
60-69% 6.9 7.9
4.5
2.6 2.7

JHARKHAND
PRADESH

NAGALAND

PRADESH

ATTISGARH
ARUNACHAL

UTTARANCHAL
HARYANA

TRIPURA

RAJASTHAN

BIHAR
MANIPUR

ORISSA

EGHALAYA

ST BENGAL

SIKKIM
KASHMIR

MADHYA
ASSAM
JAMMU &
UTTAR

PRADESH
N

ME

CHA
WES
R

J
A

Immunization coverages decrease from 4-19.6% in high performing states-(NFHS 2

to 3)
ANDHRA HIMACHAL
MAHARASHTRA MIZORAM PRADESH PUNJAB PRADESH TAMIL NADU GUJARAT DELHI KARNATAKA KERALA GOA
0

-4.4 -4
-5
-6.6
-8 -7.8
-10 -9.2

-13.2
13 2 -12
12.7
7 -12 N S 2 FI data
NFHS
50-59%
-20 60-69%
-19.6 70-79% 6
80-89%
 Immunization specific
p Initiatives
• Improving service delivery
– AD Syringes
S i th
through
h outt the
th country
t
– Alternate vaccinators in areas with no ANM and in urban areas
– Alternate Vaccine Delivery System.
System
– Increased services through catch Up rounds

• Monthly Village Health & sanitation Days

– ASHAs for tracking the children and mobilizing the community
– Additional ANMs active in Immunization

• Improving field supervision and monitoring

– Session Monitoring in poor performing states
– Implementation of RIMS in approx 300 districts
Immunization specific Initiatives
• JE Vaccination extended to 62 districts in 11
states
• Neonatal tetanus eliminated - 15 States
• Hepatitis-B implementation expanded to 10
states.
states
• Policy decisions undertaken
– To
T introduce
i t d Hib vaccine
i ini the
th UIP
– Second opportunity for measles and measles
campaigns
i
 STRATEGIES TO INCREASE IMMUNISATION IN
LOW PERFORMING STATES
Service delivery improvement
p Campaigns
Catchup p g – Immunization + other interventions ((Vit A, Deworming
g UP, Bihar, Chhattisgarh,
g
etc) Jharkhand, NE States
External quality assurance mechanism for health workers training Bihar

Quality Assurance Network for training of Health Workers Rajasthan

Outsourcing immunizations to NGOs in underserved areas Arunachal Pradesh
Incentives to health worker/ families Jharkhand, Orissa

Improving vaccine, cold chain and logistics management

Mobile Cold-Chain Workshop in Rajasthan Rajasthan
Annual Maintenance Contract for cold chain Bihar
Vaccine and logistics management assessment Orissa

Programme monitoring and supervision

District level CES Bihar, Gujrat
Partner supported monitoring UP, Bihar, Rajasthan,
Jharkhand, Orissa
Supportive supervision Jharkhand, MP
Divisional level reviews UP
9
 STRATEGIES TO INCREASE IMMUNISATION IN
HIGH PERFORMING STATES
Strengthening service delivery
PPP with medical college & youth organizations Karnataka, Mizoram
Establishing support groups Maharashtra
Engagement
g g with PRI to mobilize beneficiaries Kerala
Incentives for health workers Kerala, Karnataka
Operationalization of additional static and mobile clinics Mizoram, Delhi
Private
P i t M Medical
di l practitioners
titi iinvolvements,
l t O Outsourcing
t i Maharashtra,
M h ht G Goa, Kerala,
K l
immunization to NGOs in underserved areas Delhi
Strengthening vaccine, cold chain and logistics management
Emergency vaccine procurement fund, Vaccine stock Tamil Nadu, Maharashtra
management systems
Strengthening programme monitoring and supervision
State task force/operational core group for monitoring Kerala, Karnataka

District level supervision Punjab

Close monitoring,
Cl it i cluster
l t and d iinternal
t l evaluation,
l ti and
d Kerala,
K l K Karnataka,
t k AP (with
( ith
supportive supervision of low performing areas Medical Colleges), Tamil
Nadu, Maharashtra 10
 PROGRESS

JE Hep B
• New vaccines introduced in UIP
• Hep B in 10 states
• JE in endemic districts
• 11 Districts in 2006
• 27 districts in 2007 Highest Priority District
High Risk Districts
• 24 districts in 2008 Medium Risk Districts

• Validation of elimination of Maternal and

neonatal tetanus in
• 15 States -Andhra Pradesh,, Kerala,,
Tamil Nadu, Karnataka, Maharashtra,
West Bengal, Haryana, Goa, Sikkim,
Punjab, Chandigarh, Pondicherry,
Lakshadweep, HP, and Gujarat

• Routine Immunization monitoring systems (RIMS) introduced in all districts and being used by
nearly 180 districts
• Catch-up rounds and Immunization weeks in low performing states
11
• Training of more than 90,000 ANMs and other health workers
 IMMUNISATION: KEY ISSUES

• Shortage of vaccines and cold chain equipment

• Inconsistent delivery of vaccines to outreach session sites.
• Operational issues :
– Immunization sessions not being held regularly
– HR shortages at all levels
– Inadequate mobilityy of health workers and supervisors
at district & state levels
– Urban areas - inadequate
q health infrastructure,
multiple agencies, poor coordination.

12
 IMMUNISATION: WAY FORWARD

1. Introduction of new vaccines based on disease specific mortality and morbidity

indicators/ NTAGI inputs
• HepB-DPT-HiB Pentavalent
• 2nd Dose of measles and Rubella in select states
• JE in remaining 42 districts
2. System Strengthening :
• Operationalization of RIMS in all districts.
• Activity based funding to strengthen service delivery
• Alternate vaccine delivery to ensure reach into villages
• Alternate Vaccinators to ensure sessions are held
• Strengthening Supportive supervision
• Half yearly meeting at State with districts to ensure monitoring.
• Support
S ffor POL to assist
i active
i supervision
i i
• Demand generation through social mobilization
3. Streamline procurement and supply chain
4. Capacity Building: Training of the remainder of >100,000 health workers & managers
5. Survey of more states for MNT elimination validation 13
6 Mid term evaluation of the program against the milestones stated in the multi year plan
Achievements
Coverage in Child Immunization

15
Measles Coverage (DLHS 3)
Measles Coverage (DLHS 3)
1 state < 50%
Additional 4 States< 60%
16 states > 80% 
Fully immunized Coverage (DLHS 3)
Fully immunized Coverage (DLHS 3)

7 states < 50%
Additional 5 States< 60%
Only 3 states > 80% 
IMMUNIZATION MONITORING
 Monitoring formats
• State
• District
• Block
• Session Site